National Consumer Disputes Redressal
National Insurance Company Limited vs Jatinder Singh & Anr. on 5 January, 2021
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 545 OF 2020 (Against the Order dated 18/03/2020 in Complaint No. 127/2019 of the State Commission Punjab) 1. NATIONAL INSURANCE COMPANY LIMITED DIVISIONAL OFFICE: DIVISIONAKL OFFICE III, KOCHHAR MARKET, MODEL GRAM LUDHIANA, ...........Appellant(s) Versus 1. JATINDER SINGH & ANR. S/O. LATE SH. ARJINDER SINGH,. R/O. 1507, URBAN ESATTE, PHASE-II, JAMALPUR, LUDHIANA PUNJAB-141010 2. HERITAGE HEALTH TPA PVT. LTD., ELITE AUTO HOUSE, 54-A, GRAND FLOOR, (REAR SIDE), NEXT TO CRISIL HOUSE, ANDHERI-KURLA ROAD, CHAKALA, MUMBAI-4000093 ...........Respondent(s)
BEFORE: HON'BLE MR. C. VISWANATH,PRESIDING MEMBER
For the Appellant : Mr. Niraj Singh, Advocate For the Respondent : For Respondent No.1 : Mr. Abhimanyu Tewari, Advocate
For Respondent No.2 : NONE
Dated : 05 Jan 2021 ORDER
1. The present Appeal is filed by the Appellant against Order passed by the Punjab State Consumer Disputes Redressal Commission, Chandigarh (hereinafter referred to as the "State Commission") in MA/1857/2019 in/and CC/127/2019 dated 18.03.2020.
2. Father of Respondent No.1/Complainant obtained Medical Insurance Policy No.404000501810000094 from the Opposite Party/Insurance Company, which was valid from 05.05.2018 to 31.10.2018. The Policy covered medical expenses of USD 2,50,000/- for Illness, USD 2,50,000/- for accident, USD 25,000/-, for Personal Accident, USD 1,000/- for loss of checked in Baggage, USD 100/- for delay of checked in Baggage, USD 250/- for Loss of Passport and USD 2,00,000/- for Personal Liability. At the time of taking the Policy, the insured had disclosed that he was suffering from hypertension and diabetes. Opposite Parties got the insured medically examined and thereafter issued the Medical Insurance Policy.
3. On 05.05.2018, the Insured went to Birmingham alongwith his family. On the night of 30.08.2018, he suffered heart attack and was taken to the hospital. On 01.09.2018, Angiography was done and claim for reimbursement was filed on 03.09.2018. The Complainant's father expired on 14.09.2018. Opposite Parties repudiated the claim on the ground that the deceased father of the Complainant was having pre-existing disease. Claiming deficiency in service on the part of the Opposite Parties, the Complainant filed a Complaint before the State Commission with the following prayer: -
i. Pay the medical expenditure to the tune of Sterling Pounds 39549.63, Sterling Pounds 3645 for Repatriation services of late father of the complainant total amounting to Rs.36,30,656/- and Rs.3,34,611, as per the prevalent exchange rate total amounting to Rs.39,65,267/-
ii. Pay compensation to the tune of Rs.10,00,000/- on account of pain, mental agony and harassment suffered by the complainant.
iii. To pay litigation cost of Rs.1,00,000/-
4. Opposite Parties contested the Complaint and took preliminary objection that the Complaint was not maintainable, as the deceased father of the Complainant obtained the Medical Insurance Policy concealing the facts regarding pre-existing disease. On merits, the Opposite Parties admitted that the father of the Complainant had taken the Policy which was valid from 05.05.2018 to 31.10.2018. Insured father of the Complainant died during the currency of the Policy on 14.09.2018. Opposite Parties repudiated the claim on the ground that the insured had supressed the material fact of pre-existing disease at the time of taking the Policy.
5. The State Commission after going through the evidence and documents on record and hearing the arguments of both the Parties directed as follows:-
"i) To pay £39,549 minus 100 USD It is made clear that the exchange rate in rupees shall be prevailing as on the date of repudiation of claim i.e. 14.11.2018. The amount so calculated shall be paid along with interest at the rate of 9% per annum from the date of repudiation of the claim i.e. 14.11.2018 till realization.
ii) To pay Rs.50,000/- as compensation on account of mental agony and harassment."
6. Aggrieved by the order of the State Commission, the Appellant/Insurance Company filed the present Appeal. Heard the learned Counsel for the Parties and carefully perused the record.
7. Learned Counsel for the Appellant submitted that the State Commission passed the impugned order without properly appreciating the terms and conditions of the Insurance Policy and the extent of indemnification. It was submitted that the proposal form was to be completed by the proposer and the competent Doctor was to certify that the proposer is fit to travel abroad. In the proposal form the proposer had wrongly answered the question at A2 "Have you ever suffered from any illness or disease upto the date of making this proposal" as "NO." It was further submitted that the deceased insured had also given wrong answer to the question "Have you ever been admitted to any hospital/nursing home/clinic for treatment or observation" as "NO", though in the proposal form itself proposer had disclosed that he had undergone CABG in 1998. It was submitted that the father of the Complainant died due to heart attack and the factors leading to heart attack were Ischemic Heart Disease, Hypertension and Diabetes. Learned Counsel for the Appellant/Opposite Party submitted that exclusion clause of the Policy excludes "Pre-existing and related complications" and the father of the Complainant was having pre-existing disease and he supressed this material information from the Appellant/Insurance Company.
8. Learned Counsel for the Respondent/Complainant submitted that the insured had clearly declared in the proposal form that he was suffering from Hypertension and Diabetes and there was no question of suppression of any material fact. It was also submitted that the Insurance Company got his father medically examined before issuance of Policy. Therefore, repudiation of insurance claim by the Appellant was not justified and the State Commission rightly allowed the Complaint filed by the Respondent/Complainant.
9. It is an admitted case that the Complainant obtained Medical Insurance Policy No.404000501810000094 from the Opposite Parties, which was valid from 05.05.2018 to 31.10.2018. In the proposal form the proposer disclosed that he was suffering from hypertension and diabetes. He was also got medically examined by the doctor of the Opposite Parties before issuance of the Policy. On the night of 30.08.2018, the insured suffered heart attack and he was taken to the hospital and on 01.09.2018, Angiography was done. On 03.09.2018, claim for reimbursement of the medical expenses was filed. On 14.09.2018, father of the Complainant expired. Opposite Parties repudiated the claim on the ground that deceased father of the Complainant was having pre-existing disease.
10. Main issue in this case relates to disclosure of pre-existing disease of the insured. Learned Counsel for the Appellant, Insurance Company submitted that the insured did not disclose in the proposal form that he was having history of Hypertension and Diabetes. On the other hand, Opposite Parties admit in their reply that "father of the complainant had disclosed that the father of the complainant was suffering from hypertension and diabetes." Appellant/Insurance Company also admitted that "on second page at II B (1) History, it is clearly written CABG in 1998. CABG cannot be done without hospitalization. Before taking the Insurance Policy, the insured was suffering from Hypertension and Diabetes, which he had clearly disclosed in the proposal form. The fact that he had undergone CABG in 1998 was also disclosed and known to the Doctor as well as the Appellant. Moreover, the Insurance Company itself got the insured medically examined by a Doctor and it was after medical examination that the Policy was issued. Now, at the time of reimbursement of claim, the Appellant cannot take the plea that the proposer had supressed material fact. Being fully aware of his health status and after due Medical examination, the Appellant cannot feign ignorance of the Insured's health and deny the claim.
11. In view of the above discussion, the impugned order passed by the State Commission is justified. Appellant failed to point any illegality or irregularity in the order passed by the State Commission, warranting interference in exercise of Appellate jurisdiction Appeal is accordingly dismissed with no order as to cost.
...................... C. VISWANATH PRESIDING MEMBER